Our Services

TPRI offers a better way for claim status resolution between payer and provider by supporting the parties in the development of review standards.

The Problem

When a payer and a healthcare provider disagree on claim status, the traditional method of resolving this disagreement follows this process:

  1. Payer denies the claim
  2. Provider requests a peer-to-peer discussion with payer Medical Director
  3. After the peer-to-peer interaction, payer Medical Director denies the request
  4. Provider submits a written letter detailing the rationale for the claim status
  5. Payer denies the claim again

This process is cumbersome, resource intensive, almost always takes over a year to resolve, and frequently results in a strained relationship. After an unsuccessful written appeal, the next step of the process is often litigation and can result in terminated contracts between the parties.

From the payer’s perspective, the sense is that providers often admit too many patients as inpatient due to the inherent financial incentives and that there are many inefficiencies during the admission itself (i.e., case management delays or utilization waste.)

From the provider’s perspective, the current appeal process is unfair and biased because they are asked to jump over administrative hurdles only to present the same argument to the parties who denied the case in the first place. Providers feel that many times, payers deny a particular procedure all of the time, regardless of patient condition (i.e., “blanket denials.”)

Meanwhile, cases remain unpaid, and payer-provider tensions build.  

Our Solution

TPRI offers a better way with a fair and straightforward process for claim status resolution between payer and provider by supporting the parties in the development of review standards.

How Do We Work?

Step 1:
 Payer and provider contract with TPRI and provide their agreed-upon standards for claim status determinations. TPRI will assist in developing standards if requested.

Step 2:
When a disagreement occurs regarding appropriate claim status, the payer and provider attempt to resolve their dispute. If their efforts are unsuccessful, the case is referred to TPRI for final resolution.

Step 3:
TPRI reviews the medical record, assess the merits of the case, and applies agreed-upon standards to determine the appropriate claim status. TPRI will provide payer and provider a report with the outcome resolution of any cases submitted for review. TPRI does not have separate conversations with either party, but instead provides a report with the outcome resolution of all submitted cases. Both parties are notified simultaneously.